WHAT IS THE BEST IMPLANT POCKET FOR BREAST AUGMENTATION?
Mytien Goldberg, MD, FACS • Nov 26, 2023
WHAT IS THE BEST IMPLANT POCKET FOR BREAST AUGMENTATION?
Mytien Goldberg, MD, FACS • Nov 26, 2023
Breast augmentation is the most popular cosmetic procedure performed worldwide each year. It is popular due to high patient’s satisfaction with the procedure including women reporting improved body image, self-confidence, and overall sexual wellbeing. In a breast augmentation consult, I am often asked this question by my patients, “I was told by a plastic surgeon “below the muscle” is the best implant pocket for breast augmentation. Is that true?”
Foremost, choosing the tissue plane i.e. implant pocket for implant placement is one of the key factors in breast augmentation. Generally speaking, there are 3 types of implant pocket techniques in breast augmentation
- Submuscular pocket technique – Dual plane technique
- Subglandular pocket technique
- Subfascial pocket technique
A. Submuscular Pocket Technique – Dual Plane Technique
In this technique, the implant is placed behind the pectoralis major. This is accomplished by releasing the muscle origin at breast crease on the chest wall and along medial aspect of the rib cage up to the level of the fourth rib. This maneuver allows the muscle to window shade up on the chest wall as illustrated in image 1. The implant superior pole will be covered by the pectoralis major muscle and the lower pole of the implant is cover by the breast tissue, thus term dual -plane. (image 2)
Image 1.
Image 2.
This technique is favored by most plastic surgeons for the following reasons:
- Increasing soft tissue coverage of the upper pole of the breasts results in less rippling and prevent shelve like appearance at the top of the breast where the implant meets the chest wall
- This technique has a reported lower rate of capsular contracture around 3 to 8
- Conceptually in the dual plane pocket, the implant sits in the subglandular pocket on the lower half of the breast which allows the implant to expand the deflated skin envelope without being limited by the pectoralis major muscle, avoiding a snoopy deformity or double bubble deformity. Snoopy deformity or double bubble deformity is characterized by breast tissue that appears to slide off the implant as appear in this picture. However, the patient in this picture had a dual plane submuscular breast augmentation
There are definite draw backs with the Dual Plane technique. Here are the main draw backs:
- There is more postoperative pain after the procedure due to the manipulation of the muscle. In some very active women with very well developed chest muscles, they do complain of long term chest discomfort and weakness.
- Animation deformity is an abnormal movement of the breast and implant due to contraction of the chest pectoralis major muscle. This is an unnatural and unnerving experiences for most women with subpectoral breast augmentation. It is not often seen in two dimensional before and after pictures. It is only evidence with movement of the arms and chest. It is most prominent in thinner patients.
- Overzealous release of the pectoralis major muscle along the sternum runs the risks of symmastia and ridge like deformity up in the chest wall.
- Submuscular dynamic laterization of the implant overtime is also a real issue that is not often listed as one of the potential draw backs of this pocket location. The contraction force of the muscle will push the implant laterally into the axilla. This is especially evident when a woman lays down and the implants will slide into the lateral chest wall.
- If the pectoralis major muscle is inadequately release, accessory muscle slips over the sternum, the implants can sits far apart resulting suboptimal cleavage. Furthermore, the implants can sit very high up in the chest wall giving a unnatural high riding implant.
Main disadvantages of Dual Plane breast augmentation
- Snoopy breast deformity or double bubble
- Wide cleave due to the limit of the pectoralis major muscle
- The technique is still prone to capsular contracture as illustrated in this patient
B. Subfascial Pocket Implant Technique
In this technique, the implant is placed below the fascia which is a layer covering the muscle. It requires meticulous dissection separating this fascial layer from the muscle. Which can be performed using a Bovie cautery in a bloodless meticulous fashion as illustrated in this picture.
- Fascia layer above the pectoralis major muscle
- Provides an additional layer to cover the implant
- Protect direct contact between the implant and breast tissue therefore lower rates of capsular contracture
- Improve cleavage in wide chest women because the location of the implant is not limited by the origin of the pectoralis muscle
- Minimal rippling even in very thin and active patient
- Most importantly No animation deformity
It is a less popular technique among plastic surgeons due to the fact that it is less frequently trained technique during residency (surgical training to become a board certified plastic surgeon). However, I personally in favor the subfascial plane over the dual plane technique for multitude of reasons
- It places the implant in a very natural plane where the added volume should be centered under the breast tissue.
- It allows the implant to expand both the breast tissue and skin in the most physiologic location where the volume should be added without the restriction of the pectoralis major muscle. This prevents any potential of double bubble or snoopy breast deformity
- No manipulation of the pectoralis major muscle, a major muscle of the chest, means less immediate postoperative pain and also discomfort in the long terms for most woman. Furthermore, it does not have the dynamic deformity force caused by contraction of the muscle or lateralization of the implant in the long term.
- Furthermore, without the limits of the muscle origin on the sternum keeping the implants apart, subfascial augmentation allows a surgeon to place the implant closer together creating a much more appealing cleavage in women with wide chest anatomy as illustrated in this patient.
5. The fascial layer provides an additional layer of coverage for the implant and prevents direct contact of between the implant and the breast parenchyma (unlike the subglandular pocket), and thus lowers the rate of capsular contracture. This has been reported in large series of subfascial breast augmentation reports in the literature. The reported rate of capsular contracture in subfascial plane is similar to that of dual plane technique.
6. For most active and athletic women, the subfascial plane allows the patient to continue with their favorite activities such as lifting weight, playing volleyball, tennis, and surfing without disrupting one of the most important chest muscles (pectoralis major muscle). These patients will not have animation deformity typical of dual plane technique.
C. Subglandular Implant Pocket Technique
In this technique, the implant is placed below the breast glandular tissue. This technique is seldomly used these days due to several factors:
- It has an abrupt sharp transition from the chest wall to the implant and thus would be less natural in appearance.
- It has potential rippling deformity due to lack of soft tissue coverage
- It has a higher rate of capsular contracture compare to the dual plane or subfascial plane
However, there are advantages to this technique
- It is less painful than submuscular or dual plane technique since there is no manipulation of the muscle
- For a deflated breast – subglandular plane does allow for expansion of the skin envelope and potentially create a lifted illusion to the breast without performing a breast lift and additional scar
6 Minute Read: I received radiation treatment as part of my breast cancer treatment. What is the best breast reconstruction option for me: implant or autologous tissue breast reconstruction? If you have received radiation as part of your breast cancer treatment, I hope this blog is informative for choosing the best option for your breast reconstruction. After mastectomy, the goal of breast reconstruction is to recreate an aesthetic breast mound plus or minus the nipple and to establish symmetry with the remaining breast.
A breast lift is a surgical procedure that raises the breasts and restores their firmness and youthful appearance. It can be done with or without breast implants. As a woman ages, her breasts may sag due to a natural loss of skin elasticity, pregnancy, breast feeding, weight changes, and gravity. Breast sagging is completely natural, but it’s also reversible with a breast lift. You might be asking, what is a breast lift and how does it differ from breast implants? Breast implants make the breasts bigger and, by default, they can fill up any excess skin to cause the breasts to lift. A breast lift is a procedure that has the specific goal of raising the breasts, usually using the existing tissue. Implants are not necessary for a breast lift, though some women may choose to get them. A breast lift without implants is for women who are comfortable with the size of their breasts or women who would like a small reduction in their cup size. This procedure is also called mastopexy. During surgery, the doctor removes excess skin and tightens the surrounding tissue to reshape and support the new breast contour. The volume of the breast that fills a bra is left in tact, but their shape and position will be noticeably improved. A breast lift may be part of a ‘mommy makeover’ to reverse the affects of pregnancy and breastfeeding on a woman’s body. Since no implant is added during mastopexy, the results can be quite natural looking. Every woman is different. An individualized approach is taken for each patient to ultimately give her back youthful, firmer breasts.
Saline breast implant deflation occurs on average 4.3 to 6% at 10 years. A Study on silicone rupture rate (Inamed Silicone Breast Implant Core Study Results at 6 Years rupture rate published in Plastic & Reconstructive Surgery: December 2007 – Volume 120 – Issue ) was 3.5 percent overall at 6 year. Overall, the rupture rate of both silicone and saline implants are equivalent. The difference is detection of rupture. For saline implants, the rupture is detectable by the patient and physician almost immediately. However in case of silicone implants, the rupture is silent. It would require a radiographic study such as MRI or an ultrasound to detect silicone implant rupture. Retrospective study showed untreated silicone gel fill implants are harmless conditions (Plastic & Reconstructive Surgery: July 2004 – Volume 114 – Issue 1). Unlike a silicone implant, saline implant ruptures result in an immediate deflation of the implant and skin envelope of the breast. If the deflation goes untreated, the breast skin envelope would retract back while the other breast envelope continues to be expanded. Over time, you would have significant asymmetry in your breast that may require additional procedure to the unaffected breast such as a lift. Therefore, if you have breast implants and note any changes in your breast shape or size, you should consult your plastic surgeon soon for diagnosis and treatment. If it is a breast implant rupture, the two major breast implant manufacturers in the United States (Allergan and Mentor) provide a lifetime warranty for all of their implants. If an implant fails or ruptures during the first 10 years, both companies will provide a new implant and $1200 applicable toward operating room and anesthesia costs which can be upgraded to an extended plan providing up to $2400 for a small fee prior to surgery. All implants have a lifetime guarantee and will be replaced by the manufacturer if the problem is related to the implant.
In America and throughout the world, both men and women are expected to look healthy and young well into their 30’s, 40’s, 50’ and 60’s. While diet and exercise can play a large role in looking younger, the use of modern cosmetic surgery has become one of the most popular ways to beat back the clock. Getting surgical cosmetic procedures has become very commonplace, with an ever-growing percentage of the population opting in to get cosmetic surgery. Yet there is a large divide between women and men, and what procedures are most popular for each of the sexes. The American Society of Plastic Surgeons today released top line data from its 2011 plastic Surgery Statistics Report. The latest data shows breast augmentation is still the most common cosmetic surgery procedure for 2011. There were 307, 180 breast augmentation procedures performed in 2011, up 3.7% since 2010. Many of the common signs of aging that occur to a woman’s breasts as she gets older can be very devastating to her self esteem. Yet with today’s modern surgical options, there is a viable option for women to change the way they look. Second to breast augmentation, rhinoplasty is the most popular cosmetic procedure, with a total of 243,772 procedures being performed in 2011. The growing number of cosmetic procedures is an indication that even in this tough economic climate, more consumers are choosing cosmetic surgery as a way to look younger and feel better about themselves. We certainly see the same trend in our practice. More and more women are seeking improvements in their look. We support this trend as many of these procedures equate to improvements in their overall self-confidence and quality of life.
A new study published in the Archives of Facial Plastic Surgery in February 2012, looks at perceived age after facial plastic surgery. This novel study attempts to quantify the degree of perceived age change after facial plastic surgical procedures . A total of 60 patients were enrolled in the study and divided into 3 groups: Group 1 patients had only facelift and neck lift (total of 22 patients); Group 2 patients had facelift, neck lift, upper and lower eyelid surgery (total 19 patients); and Group 3 patients had facelift, neck lift, upper and lower eyelid surgery, and brow lift (total 21 patients). The investigators then asked a group of first year medical student to estimate the patient’s age based on the Before and After pictures of each patient. The researchers tried to standardize the photographs by asking participants to not wear makeup. The researchers found that on average, the raters estimated that the patients looked 1.7 years younger than their actual age before surgery, and 8.9 years younger afterward. On average, the estimated age dipped by 5.7 years in group 1 (patients with neck and face lift), and by 8.4 years in the third group (patients with neck, face lift, upper and lower eyelid and brow lift). Therefore, the author of the study concludes that facial rejuvenation surgeries demonstrate a significant and consistent reduction in perceived age. This effect is more substantial when the number of surgical procedures is increase. The desire to improve one’s physical presentation and to maintain a youthful appearance is intrinsic in our evolution. Physical appearance and how we are perceived by others have implications for social and psychological functioning, as well as our sense of well-being, self-esteem, and self-confidence. Before you seek to have plastic surgery procedures, do your homework and check that the doctor is board-certified in plastic surgery. There is a lot of white-coat deception. Virtually any kind of doctor legally claims to be a plastic surgeon without any formal training in plastic surgery. As a board certified plastic surgeon, I have seen increasing numbers of patients who present with complications and unsatisfactory outcomes after having procedures done by non board certified plastic surgeon.
Today’s society is one in which we can never seem to get enough. Everything is bigger, better, faster, and stronger. But what happens when you are blessed with too much of a good thing? While many women desire an increase in breast size, there are those who feel uncomfortable with size of their breasts. If a woman has large breasts, she may be considering breast reduction surgery for many reasons. Aside from feeling more comfortable in their bras and clothing, breast reduction surgery can help alleviate any number of symptoms. Women with large breasts often suffer from chronic back and neck and shoulder pain, chronic rashes and skin irritation under the breasts, deep grooves in the shoulders from bra strap pressure, poor posture and restricted activity, as well as poor self-image due to large breasts. Breast reduction surgery, also known as reduction mammoplasty, removes excess breast fat, glandular tissue and skin to help achieve a breast size that’s more proportionate to a woman’s body, as well as helping to alleviate the symptoms associated with overly large breasts. So who is breast reduction surgery for? Women of all ages have been known to have breast reduction surgery, even young women in their teens; however it’s strongly recommended that the patient wait until they are past the age of development. If a woman hasn’t started a family yet, or is still in the stages of family planning, it may be best for her to wait until pregnancy isn’t an issue yet, as pregnancy can change breast tissue. Results can be seen immediately, but it’s best to keep in mind that it can take months for the swelling to completely diminish and for the surgical scars to fade. For anyone considering breast reconstruction surgery, consult a Board Certified plastic surgeon. This is a very personalized procedure, and it’s important to understand everything that breast reduction surgery encompasses, including possible risks and complications, as well as set realistic expectations. I have insurance. Does that cover any of my procedure costs? If a patient has a history of chronic conditions, such as back, neck, or shoulder pain, or chronic skin conditions such as rashes or skin irritation in the breast issue, having a breast reduction may be considered medically necessary and is covered by most insurance plans. If approved, this means the patient’s insurance would cover the cost of the surgeon’s fee, as well as the cost of the facility and anesthesiologist. This is something that should be discussed and documented during a consultation with a board certified plastic surgeon. http://www.plasticsurgery.org/reconstructive-procedures/breast-reduction.html http://www.mayoclinic.com/health/breast-reduction-surgery/MY00778
Do Breast Implants Lift There are many cosmetic surgery procedures commonly performed on the breasts and those who have not researched them before are often unfamiliar with what each procedure is intended to address. We were recently asked if breast implants can achieve some lifting of sagging breasts. In truth, women with sagging breasts are facing an issue of excess skin, which is often caused by fluctuations in weight, aging and gravity or the trauma of childbirth and breastfeeding. An implant will indeed make the breast larger, but the amount of excess skin commonly concerning women who consider their breasts to be sagging is generally much more skin than would be occupied by a reasonable sized implant. Furthermore if an implant is added to sagging breasts in which the nipple is facing downward, the location and direction of the nipple will remain in nearly the same position and orientation even afterwards. A breast lift is a procedure in which the skin of the breasts is first pulled taught. After which the excess skin is removed and the nipple is relocated at the proper level and angle to assure that the breast appears balanced and youthful. Although a breast lift makes the breast look more youthful, smooth and firm it will often make the breast appear slightly smaller because of the excess skin being removed. While breast implants alone cannot full address concerns of sagging breasts, breast lift procedures are specifically designed to address sagging breasts. One popular option that many women who are concerned with both sagging breasts and the current or post-op breast size now choose is to have a breast lift with breast implants , which can be done in one procedure or the two can be done separately. This allows patients to increase the size of the breasts while simultaneously addressing the issue of saggy breasts. Breast implants alone, even large ones, will likely not prevent sag in breasts that are already sagging. Sagging breasts should be treated with a breast lift but can include implants. A breast lift with breast implants is a great option for those who are afraid of losing mass or cup sizes after a breast lift and for those who would like slightly larger breasts as well as a firmer and fuller shape free of sag.
Breast Reduction Surgery Breast reduction surgery is a surgical method of reducing the size of the breasts. A breast reduction procedure is most commonly performed for women who have breasts that are too large in relation to their body frame, women who have shoulder, neck or back problems caused by the weight of the breasts, women who are restricted from physical activity due to the size of the breasts, and for women whose breasts are large enough to cause body image and self-esteem issues. Breast reduction can attend to one or both breasts if they are disproportional or if they differ in size. Breast reduction surgery is available to any patient whose breasts have completed physical maturation. One of the most significant factors involving the size and shape of the breasts is pregnancy and breast-feeding which can dramatically change the shape and size of the breast and some doctors may recommend waiting until after childbirth, although this is not a rule. Patients should also be in good physical health and be non-smokers. Patients who regularly smoke and wish to undergo breast reduction surgery may be asked to quit for several months before and after the procedure. Patients will also need to refrain from the use of Aspirin and other anti-inflammatory drugs that thin the blood and can cause a risk of bleeding during surgery. How is the breast reduction procedure done? During a breast reduction procedure, the surgeon will make 3 main incisions and generally they are all that are necessary. The first incision runs from the areola down to the base of the breast. The second incision runs along the underside of the breast and follows the curve of the breast. The final incision traces the aureola so that the nipple can be repositioned after breast tissue has been removed. The nipples remain connected to the underlying tissues in an effort to retain function and sensation. The size of the aureola can also be reduced before repositioning to help balance the proportion between the size of the breast and the nipple. Be sure talk with your surgeon about any future plans to have children and express any concerns regarding breast function. A breast reduction procedure can be performed in a hospital or at a surgical center and takes anywhere from 2-4 hours on average. During this time the patient will remain under general anesthesia to prevent pain and will not feel or remember anything. Although a breast reduction is a major surgery, it is usually considered an outpatient procedure, meaning patients are allowed to return home afterwards and do not necessarily require an overnight stay. Some patients choose to stay at a post surgical recovery center the first night after surgery to make sure they get the optimal care and attention available. There are multiple variations on procedures and a surgeon will be able to determine what is best for each patient. The most important thing patients can do to make sure surgery provides the best results is to stay healthy in the weeks and months leading up to surgery, and get plenty of rest and take care of the body afterwards. It is vitally important to follow the advice of the surgeons as closely as possible and not to rush back to strenuous activities. Most patients are able move about after several days and with the help of post-surgical compression bras may be able to return to work in around 2 weeks with the approval of the surgeon during check ups. Vigorous activities should initially be avoided but should slowly be eased into as advised by surgeons. While the breast will be very swollen and tender for at least the first couple of weeks, swelling and discomfort will subside fully over the course of several months and patients will be able to return to wearing normal bras and finally get an idea of what the final outcome will be.